International Journal of Play Therapy, 15(1), pp.

87-100

Copyright 2006 APT, Inc.

EFFECTIVE PARENT CONSULTATION IN PLAY THERAPY

Jennifer Cates
Central Washington University

Tina R. Paone
Monmouth University

Jill Packman
University of Nevada

Dave Margolis
Practicing Clinician

Abstract: Effective communication with caregivers can contribute to successful play therapy outcomes. This article examines the structure of parent consultation in play therapy. The components of effective parent consultation are outlined, from the initial phone interview through termination, to provide guidance to play therapists for communicating with caregivers throughout the therapy process.

A thorough review of the literature suggests that authors agree on the importance of parent consultation in maximizing the benefits of play therapy (Kottman, 2003; Landreth, 2002; McGuire & McGuire, 2001; Van Fleet, 2000). Much has been written on the concept of parent consultation in various play therapy books; however, a brief consolidation of the important points in the consultation process may be of benefit to play therapists looking to increase their understanding of therapeutic collaboration with caregivers and how communication affects the outcome of the play therapy process. Parent consultation in conjunction with play therapy has been noted to improve the chance of successful treatment (Kottman & Ashby,
Jennifer Cates, M.A., MFT, NCC, is a doctoral candidate and assistant professor at Central Washington University. Tina Paone, M.A., RPT, NCC, is a doctoral candidate and assistant professor at Monmouth University. Jill Packman, Ph.D., RPT-S, NCC, is an assistant professor at the University of Nevada, Reno. Dave Margolis, M.A., MFT, provides play therapy to children in the Chicago, II area. All correspondence regarding this article can be sent to Jennifer Cates at the University of Nevada, Reno, Department of Counseling and Educational Pyschology, MS 281, Reno, NV, 89557.

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1999). According to Landreth (2002), helping caregivers understand the process of play therapy may be one of the most important tasks of a play therapist, as caregiver cooperation is essential in order to get a child into therapy. However, play therapists sometimes avoid thorough parent consultation due to a lack of understanding of the process or of the caregivers. Following parent consultation guidelines may help to counteract a play therapist's hesitancy to work closely with caregivers. Additionally, a clear structure for consultation may minimize caregivers' defensive reactions and increase the chances of a positive response to therapeutic recommendations (Kottman & Ashby, 1999). Play therapists that listen to, validate, and build a therapeutic relationship with caregivers create partners who are willing and able to alter the attitudes, perceptions, and behaviors necessary to support their child's treatment (Kottman, 2003). Caregivers who are uninformed about the process of play therapy are more likely to terminate their child's treatment simply for a lack of understanding of what is occurring during therapy (Athanasiou, 2001; Berryman, 1957). A number of factors may influence a caregiver's decision to terminate a child's treatment prematurely. Among these factors may be doubts about the value or effectiveness of play therapy, unrealistic expectations of quick fixes, and the expected use of talk therapy. It has been suggested that there is a positive relationship between the accuracy of caregiver expectations of therapy and the number of kept appointments (Shuman and Shapiro, 2002). Caregivers' motivations for seeking therapy for their child may also impact the level of participation in the process, especially if courtordered or coerced into the counseling process by a spouse or partner (Van Fleet, 2000). Caregivers are frequently the most important people in a child's life, so caregiver resistance to play therapy has the potential to hinder the treatment process, producing less than optimum outcomes (Van Fleet, 2000). However, if the therapist focuses on developing a therapeutic relationship with the child as well as the child's caregivers, chances for the child's successful completion of treatment can be increased (Van Fleet, 2000; LeBlanc & Ritchie, 2001). In conceptualizing communication strategies, it is important to consider caregivers'

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motivations for seeking play therapy and their expectations about the process.
Initial Parent Contact - By Phone

From the initial communication with caregivers until the last, a therapeutic intention can be planned and modeled. It is important to remember that caregivers seeking counseling for their children may be experiencing a multitude of uncomfortable thoughts and feelings themselves (Holmberg & Benedict, 1997; Landreth, 2002). In order to join with the caregivers, attending skills may be useful so that they have a sense of being understood by the therapist. Caregivers may often be feeling frustrated, guilty, afraid, or confused about what to do for their child. Therefore, it may be helpful for the therapist to be responsive to the dynamics underlying a caregiver's communication of the presenting issues by using reflective listening (Landreth, 2002). With this sensitivity in mind, efforts are made to gain a preliminary understanding and history of the presenting issues. However, limiting reflective statements may be important to minimize the length of a phone conversation. Often, sensitive issues, such as detailed caregiver concerns, are better suited for the intake session. Sharing of the basic structure of the play therapy process may also be helpful to include in the initial communication with caregivers. Explanation of fees, session time and length, and expectation of caregiver involvement are appropriate to discuss. A short explanation of play therapy and the therapist's theoretical approach to the process of play therapy is recommended (Kottman, 2003). During this initial contact it is also suggested that the therapist take the opportunity to briefly explain the rationale for use of play versus talk therapy for children, including the nature of the therapeutic relationship and its potential for a positive impact on the child's development in all domains - physically, emotionally, cognitively, socially, and spiritually (McGuire & McGuire, 2001). At this point, it may be important to be as concise as possible in order to not inundate the caregivers with too much information. Allowing time to ask questions during the course of the initial communication can contribute to the building of a therapeutic alliance

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between the therapist and caregivers, which is essential to the child's success in therapy (Webb, 1999). Intake Session Ideally, the intake session is face to face with the caregivers only. If at all possible, both parents should be invited and encouraged to attend the intake session. Any adult figure who is involved in the child's life can provide important information about the child and family dynamics, as well as have a significant impact on the child throughout the course of therapy. The initial meeting without the child present will allow caregivers to openly express their concerns, as well as create an opportunity to continue to build a strong caregiver/therapist alliance (McGuire & McGuire, 2001). The primary goals of this initial session are to continue to establish rapport, gain a clearer understanding of the caregivers' reasons for seeking counseling for the child, establish preliminary treatment goals, and to further educate the caregivers about the play therapy and parent consultation processes (Kottman, 2003; McGuire & McGuire, 2001). Cultural Considerations. It is important to reflect the values and world views of all families through creating a culturally sensitive organization (Gil & Drewes, 2005). Having bilingual staff members and designing a reception area that is reflective of a diverse society demonstrates a commitment to inclusiveness for all clients and may be important for establishing rapport with racial/ethnic minority families. Decorations and reading materials can be selected to represent a variety of cultural groups. In addition, setting up the play therapy room with culturally sensitive arts and crafts, toys, dolls, and games will benefit families from all five major racial/ethnic backgrounds. In their book, Gil and Drewes (2005) provide a detailed list of resources for selecting reading materials and culturally appropriate play therapy items. Establishing rapport. Just as in all sessions, attending skills are essential during the intake session. McGuire & McGuire (2001) recommend the use of the "question-response-reflect cycle" in order to assure that caregivers are understood and validated. This consists of the therapist asking questions about the presenting problem, the caregiver

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responding, and the therapist reflecting these responses. Use of this cycle will aid caregivers in expressing their feelings, clarifying their thoughts, and eventually establishing goals for treatment. In this first meeting, it may also be helpful to encourage caregivers for their strengths and note what they are already doing well in order to help them reconnect with a sense of hopefulness and self-respect (Kottman, 2003). McGuire & McGuire (2001) note that only after trust is developed can the therapist begin to gather data. Gathering data. Landreth (2002) and Kottman (2003) both recommend gathering background information in order to develop rapport and increase understanding of therapeutic goals. Kottman, in particular, encourages gathering a detailed history of the problem, a developmental history of the child, and information about daily routines, family interactions, and past trauma. Some useful tools for gathering data include: the Vineland II Adaptive Behavior Scale for Children Parent/Caregiver Rating Form (Sparrow, Cicchetti, & Balla, 1984), the Child Development Inventory (Ireton, 1992), and the Behavior Assessment System for Children- Structured Developmental History (BASC, SDH) (Reynolds & Kamphaus, 1992). These assessments can provide information about a child's experiences at school, changes in the home environment, or late or early developmental milestones which may give the therapist insight into the origin of the problem. In addition to finding out specific information about the child, it may be useful to discuss what other issues in the family are affecting the child's behavior. When appropriate, the play therapist may recommend that caregivers seek out individual or couples counseling, or refer them to other community resources, such as parenting classes or self-help groups (Kottman, 2003; Landreth, 2002). While gathering data the therapist should inquire about cultural factors that may influence the relationship with the child and family. In order to gain a more complete understanding of what behaviors are valued and considered normal by the child and family, it may be helpful to explore cultural variables, such as race/ethnicity, religious preferences, socioeconomic status, sexual orientation, gender roles, and differences in abilities. Additionally, variation in cultural backgrounds between the

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therapist and client may require more time for rapport development and may need to be addressed directly (Gil & Drewes, 2005). In order to maintain a positive relationship with caregivers, it may be useful for therapists to engage in a reflective process, such as consultation or journaling, in order to process thoughts and feelings. Negative attributions toward the caregiver that stem from cultural differences can often arise and interfere with rapport building and undermine therapy. Explaining the process. Anderson & Anderson (1984) suggest that providing caregivers with a good understanding of the play therapy process and how it works is important. It is helpful to reiterate the rationale for using play rather than talking to their child, as this is the fundamental basis for play therapy. Additionally, it can be helpful for therapists to predict the general course of therapy by explaining that a child may experience an initial period of improvement, followed by a worsening of symptoms, and then eventual mastery of new behaviors and acquisition of more positive attitudes toward self and others. It is important to communicate that every child reacts differently to play therapy (Guerney & Guerney, 1989). Caregivers often want to know how long the play therapy process will take. It may be helpful if caregivers understand that children learn and develop at different speeds, and consequently, treatment length will be determined through a collaborative process tailored to the individual child. Anderson and Anderson (1984) recommend discussing that there are few limitations in the playroom. As long as there is not harm to self, others, or damage of property, the child will be allowed to play as needed. In their everyday worlds, children encounter many external rules that they are required to follow. Play therapy offers an opportunity to shift from an external locus of control and gives children a chance to experiment with their internal values and develop self reliance. Fewer limits also provide children with a sense of power by allowing them to make their own decisions and decide what to play with and what to do. It may help if caregivers understand that this freedom of play allows children to express feelings and problems. Often, caregivers may be concerned that their child will expect the same freedom of play at home. Therapists can explain that by developing self reliance and an internal

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locus of control, children learn to understand that limits are different in various settings.
Communicating about play therapy. Along with building the

caregiver/therapist alliance, gathering information, and explaining the process, the initial meeting with caregivers presents the opportunity to suggest ways to introduce play therapy to their child. Avoiding expressions that suggest that the child is the problem contributes to a positive relationship between the therapist and the child. Phrases such as "fix your problems," "bad feelings," or "therapy" may contribute to derogatory perceptions of self for the child, as well as initial negative expectations of therapy (McGuire & McGuire, 2001). Play therapists can demonstrate how to communicate with children about play therapy (Anderson & Anderson, 1984; McGuire & McGuire, 2001). With regard to explaining to the child where s/he is going, Landreth (2002) recommends that caregivers say, "You're going to see [therapist's name] in a special playroom with lots of toys for you to play with" (p. 169). If the child wants to know why, caregivers can be taught to say, "Things don't seem to be going well for you at home...," or "Sometimes it helps to have a special time just for yourself to share with a special person" (p.169). Within this context caregivers may be taught to reflect their child's feelings about attending play therapy in order to relieve anxiety about being in an unfamiliar situation (McGuire & McGuire, 2001). Explaining the child's privacy. Many caregivers greet their child after a play therapy session by asking, "Did you have fun?" or "What did you do today?" Many authors agree that the first meeting is a good opportunity to help caregivers understand how to communicate with their child about their experiences in play therapy (Landreth, 2002). Landreth suggests a discussion about the importance of the child's privacy so that caregivers are discouraged from asking their child about the play therapy session when they come out of the playroom. He suggests that caregivers instead say, "Hi. We can go home now" (p. 168). It is common for a child to bring an arts or crafts project out of the play room to show their caregivers. While it is the caregivers' natural instinct to praise the child's project, Landreth recommends that the therapist educate the caregiver about refraining from praise, instead encouraging

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them to focus on reflection of the child's feelings or actions. For example, caregivers can be guided to say, "You're proud of what you did." Additionally, the therapist may explain that s/he will only talk to the caregivers in general themes about the child's progress (Anderson & Anderson, 1984; Landreth, 2002). Ethical and legal issues. While the child's confidentiality is of the utmost importance in maintaining the therapist/child relationship, it is important that both caregivers and children (depending on the developmental level and age of the child) understand the limits to confidentiality. These limits vary from state to state but generally include child abuse, elder abuse, when a child threatens to harm herself or himself, and when a child threatens to harm someone else. Children should not be coerced into therapy, so it may be helpful for them to give their assent to participate in the process. Children are defined by the U.S. Department of Health and Public Service (Penslar & Porter, 1993) as those who have not yet reached the legal age of consent. These children typically fall between the ages of 7 and 17. For all clients, it can be helpful to have both parents give informed consent when possible. If the child has parents/guardians that live in different homes, Landreth (2002) recommends that the therapist obtain a copy of the most recent court order to verify legal guardianship. Therapists are required to have informed consent for treatment from all legal guardians before treatment begins. Additionally, it is imperative that therapists obtain separate permission forms before releasing information to anyone other than the legal guardians or before audio or video recording any sessions. Playroom tour. Landreth (2002) encourages the therapist to give caregivers a tour of the playroom and to discuss how the first meeting with the child will unfold. It may be important for the caregiver to understand that the focus will be on the child and that caregiver questions or comments can be addressed during ongoing parent consultations. Landreth (2002) also recommends telling caregivers about how the initial session with the child will start in that the therapist will state to the child that it is time to go to the playroom, and that the caregiver can respond with, "I'll be here when you are finished playing" (p. 170), rather than saying "bye-bye," to let the child know that s/he is

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not being abandoned with a stranger. The therapist can explain that children react in many different ways to the first play therapy session and that if the child wants the caregiver to come to the playroom, the therapist will respond for the caregiver and let her or him know what to do (Landreth, 2002). Setting a consultation structure. The play therapist can create both a play therapy approach and a parent consultation structure that is consistent with her/his own theoretical orientation. Some approaches may be long term and more insight oriented, others may be brief and solution focused, some may focus on family systems and involve many family members, and still others may require less caregiver and family contact. It is important to pay close attention to cultural factors when creating a structure for play therapy and parent consultation, so that the theoretical orientation and approach can be tailored to be consistent with client value systems. Kottman (2003) recommends emphasizing the importance of caregiver involvement with their children at home, in school, and in play therapy. She suggests that therapists talk with caregivers about the benefits of changing their own behaviors, such as improving communication and attending consults, in order to help their child. Therapists vary in their theoretical orientations and their approaches. Some therapists schedule meetings with caregivers once a month, while other therapists schedule with caregivers as needed or allow for regular contact by phone (Landreth, 2002; Webb, 1999). Kottman (2003) typically allows for twenty minutes with the caregivers and thirty minutes with the child each session. However, she notes that caregiver consult time may vary depending on family needs or the play therapy setting. Creativity and flexibility may be useful when considering caregiver needs, as well as demands on the individual therapist's time. Landreth (2002) recommends informing the child that a caregiver meeting will be taking place and to meet with the caregiver first so that the child does not perceive that the therapist is telling the caregiver what the child has just done during the play therapy session.

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Ongoing Parent Consultation The primary goal of ongoing consultation is to continue to develop and maintain a strong and trusting rapport with the caregivers. Through the use of attending skills and reflective listening, the therapist can use the consultations to empathize with the caregivers, give updates on the child's progress in play therapy, inquire about the child's behaviors, modify treatment goals, provide education, encourage advocacy, and facilitate appropriate closure of the therapeutic relationship with the child and the caregivers. Treatment goals. The therapist may elicit information about which of the child's behaviors are changing and which of them are staying the same. It may be helpful to continually monitor whether the goals of therapy are being met and to clarify understanding of the child's behaviors at home, school, and in other settings. This will increase the therapist's understanding, as well as encourage the caregivers to observe their child's behaviors. After listening to and validating caregivers' concerns, it may be helpful to inquire about what they see as the child's strengths. Reframing frustration and anger as care and concern can help caregivers to examine other feelings they may be experiencing and to help them increase empathy for the child. Additionally, this will encourage caregivers to notice more of the child's positive behaviors (O'Connor & Schaefer, 1994). Education. Often, it is difficult for children to maintain change from their play therapy sessions without some adjustments in their home environment (Kottman, 2003). It can be helpful to educate caregivers on reflective listening, limit setting, giving choices, validating feelings, and following through with consequences. These are the skills that will have a lasting impact on the caregiver/child relationship and improve the caregivers' ability to understand and communicate with their child (O'Connor & Schaefer, 1994). Guerney & Guerney (1989) attribute lack of parenting knowledge, not parent character deficiencies, to child behavioral problems. Educating caregivers about development and encouraging them to learn about parent/child communication can increase caregiver curiosity about their child's appropriate and evolving behaviors. Morris (1974) also recommends informing caregivers about

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the tendency for behavior to worsen temporarily as a new stage of development is encountered. For example, as a child begins school, it becomes important to develop the capacity to work and cooperate with others. Caregivers may notice an increase in disruptive behavior at home as children make this adjustment. This kind of caregiver education can alleviate anxiety in response to normal developmental transitions. Advocacy. Frequently, a child that is participating in play therapy will be struggling in other social contexts besides the home. The therapist can coach the caregivers on how to advocate for their child at school by teaching them to communicate with teachers, counselors, and administrators. The therapist can role-model this advocacy by getting a release from the caregivers to talk with the child's counselor and/or teachers (Sweeney & Homeyer, 1999). Termination. As play therapists build relationships with children and caregivers, proper termination becomes vital. Ideally, termination occurs when the caregiver and therapist agree that the goals of therapy have been met, and the therapist has observed that the child's attitudes, self-expression, and behaviors have changed (Benedict, 2003). Depending on the relationship, it may be necessary to discuss termination over several sessions with both caregivers and children, in order to make the transition as smooth as possible. Informing caregivers of the importance of this process can prevent abrupt and sudden termination. Additionally, it may be beneficial to prepare caregivers for the possibility that their child's sadness about no longer participating in play therapy may be expressed through a relapse in behavior. Encouraging caregivers to continue using the skills they have learned while the child was in play therapy, such as reflecting and limit setting, may be sufficient for addressing these concerns. If, however, the behavior continues, caregivers should contact the play therapist to discuss options, one of which may be to schedule follow-up sessions to make the termination process more gradual for the child and the caregiver.

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CONCLUSION Parent consultation is referred to by Athanasiou (2001) as collaborative problem solving, allowing for specific intervention strategies directly tailored to the caregivers' needs. Upon in-depth examination it becomes clear that effective work with caregivers is an essential part of the play therapy process. Caregiver/therapist alignment can improve child attendance to sessions and caregiver compliance with treatment recommendations. It can help to clarify treatment goals, explore systemic issues, and provide an opportunity for teaching new skills. Effective parent consultation can increase the likelihood that change of behavior will be transferred from the play therapy sessions to home, school, and other settings, having a positive, lasting impact on children, their families, and their larger social contexts.

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